Care Management Nurse, San Francisco, CA
Care Management Nurse
Job ID 2017-1063
Job Locations US-CA-San Francisco
Category Health Services
Type Regular Full-Time
More information about this job
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. San Francisco Health Plan is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
The Care Management Nurse will provide medical case management or consultations on all cases assigned to their team’s Community Coordinator depending on the needs of the case and case type. Nurse case management includes medical assessment and care planning, chronic condition teaching aimed at self-management, and post-discharge follow-up medication reconciliation.
The RN will conduct telephonic and in person nursing care management medical assessments, perform home, facility and community based visits when needed, as well as provide medical/nursing ongoing consultation to the Community Care Coordinators. The Nurse Care Manager will work closely and have regular supervisor meetings with both their LCSW Supervisor and the SFHP Medical Director.
WHAT YOU'LL DO
- Coordinated care management/ coordination of care activities with the assigned primary Community Coordinators ensuring all medical needs are met
- Ability to provide nursing input on all cases referred and open within their assigned clinical team; up to 150 cases at any given time.
- Responsible for performing care management within the scope of licensure for members with complex and chronic care needs
- Provide consultation to Community Coordinators on medical prioritization of a member’s care plan and outreach to medical care team members (such as PCP, Specialist, Hospitalist, and ancillary providers) as needed
- Perform duties telephonically or on-site at local hospitals for case management or coordination of care. Primary duties may include, but are not limited to:
- Conduct medical assessments to identify individual needs and inform creation of member-centered care plan in collaboration with Community Coordinator
- Coordinate with Utilization Management and Pharmacy teams on members medical and pharmacy needs.
- Ensures member has access to services appropriate to their health needs.
- Monitors and routinely updates the medical care plan to match member’s motivation and priorities
- Interfaces with member’s PCP and SFHP Medical Directors on the prioritization of treatment plans.
- Collaboratively initiate, and participate in care conferences
- Provides targeted medical interventions focused on chronic condition teaching, assessment and development of member’s self-management skills and prioritization of medical needs.
- Coordinates care across settings and helps patient/families understand health care options Home and facility visits as needed
- Review member’s medical history in multiple Electronic Medical Records (EMRs) and summarize key medical information in our care management system, Essette.
- Coordinate care to promote proper care access and care continuity, especially during transitions of care. Care may address the individualized health, behavioral or social needs of the member.
- Adding nursing/medical perspective to interdisciplinary team management of patients with complex needs.
- Engage in ongoing interdisciplinary, intra-organizational collaborations and serve as a nurse liaison to SFHP partners, such as governmental agencies and community based organizations.(CCS, GGRC, LEA, etc.)
- Ensure appropriate levels of service coordination where appropriate with Community partners, including Behavioral Health, CCS, GGRC and other partners.
- Participate in discharge planning from acute inpatient stays
- Work collaboratively with Community Coordinators to -develop the psychosocial history and priorities of the member.
- Use nursing/medical expertise and experience to support team outreach, engagement, and ongoing management of members regarding chronic disease management, health services use, and medication management.
- Serve as liaison to clinic based primary care physicians and specialists to engage providers in care plan development and follow-through with a goal of ensuring cost-effective quality care.
- This position does not directly manage personnel, but requires team work with licensed and non-licensed staff.
- This position is based at SFHP, but will likely require travel within San Francisco as a part of the essential duties for member, provider, and community visits.
WHAT YOU'LL BRING
- Active California RN or LVN license without restriction and 3 years minimum experience in case management, discharge planning, or equivalent experience. CCM certification preferred
- BSN, MSN, or equivalent work experience in lieu
- RN, or LVN with experience in Case Management
- Must be knowledgeable in Case Management/Care management practices to meet needs of medically complex as well as those with complex psychosocial needs Strong medical knowledge of common medical conditions, including but not limited to: diabetes, End-Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Liver Disease, Hep C and chronic wounds
- Experience with NCQA, Complex Care Management
- Knowledge of San Francisco County community resources, Medicare and Medi-Cal.
- Knowledge of Health Plan/ Integrated Delivery system models of case management and care coordination best practices.
- Experience with Medi-Cal and or Department of Health Service regulations and standards preferred but not required
- Population-based perspective on care delivery and access disparities for vulnerable patient populations
- Ability to conduct home and other community based visits; 25-50% travel
- Experience educating members, their families and medical providers on post-discharge needs
- Experience with coordination of care for members requiring services from community agencies, the department of public health, and Medi-Cal carve-out and waiver programs.
- Ability to collaborate with team members on cross-departmental improvement efforts, quality improvement projects, and optimization of cost management, member satisfaction improvement, and projects centered on decreasing avoidable ER and inpatient use
- Excellent oral and written communication skills
- Ability to work with socially and ethnically diverse populations
- Proficient use of common Microsoft Word applications such as Word, Excel, Outlook and Access.
- Bilingual in Cantonese, Vietnamese, or Spanish preferred but not required
- Because this position may require member home visits, the incumbent must successfully complete a sex offender registry screen
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.